University of West Florida Sports Medicine

[Pages:21]University of West Florida Sports Medicine

Dear Argonaut,

On behalf of the UWF Sports Medicine Staff, I would like to welcome you to UWF and congratulate you on joining the UWF Athletic Department. I would like to take this time to inform you that prior to receiving your pre-participation physical at the beginning of the semester all medical forms must be completed and turned into the sports medicine facility at UWF. Each form must be completed and signed. Also you will be required to submit all medical notes, surgery notes, and imaging results, etc. We wish you luck during your career here at UWF and look forward to assisting you with your sportsmedicine needs. If you have any questions email me at jgamber@uwf.edu

Arnold Gamber

Pre-participation Check List

Personal Information Form

Medical History Packet

Insurance Forms

Medical Consent Forms

Supplementation Form

ADHD Forms (if Applicable)

Nutrition Form

All Medical Notes submitted to UWF Sports medicine

(Dr. notes, Surgery Notes, MRI/X-Ray reports, any other medical paperwork)

Please mail all forms to: University of West Florida ATTN: Athletic Training Room 11000 University Parkway

Pensacola, FL 32514

University of West Florida Sports Medicine

Personal Information

Name of Athlete: ____________________________ DOB: ____________________

Student ID#: ___________________________ Sport: _________________________

Email Address:

Cell Phone:

Address while attending UWF:

City:

State:

Zip Code:

Home Address:

Home Phone:

Home City:

State:

Zip Code:

Parent Information Father Name:

Cell Phone:

Address:

Home Phone:

City:

State:

Zip Code:

Mother Name:

Cell Phone:

Address:

Home Phone:

City:

State:

Zip Code:

Emergency Contact Information (must be located in the United States)

Name:

Home Phone:

Address:

City:

State:

Zip Code:

Cell Phone:

Employer:

Work Phone:

University of West Florida Sports Medicine

PLEASE READ THE FOLLOWING CONSENT FORMS CAREFULLY:

(If you are under 18 years of age, a parent/legal guardian must also sign.)

The basis content of each is A. Medical Consent

B. Medical Care Statement C. Shared Responsibility

For Sport Safety

D. Authorization for Release Of Information

Allows UWF athletic trainers and physicians to treat any injury/illness you sustain while being an athlete at UWF.

Informs you of provision for payment of medical care.

Informs you that there are certain inherent risks involved in participating in intercollegiate athletics and that you are willing to assume responsibility for such risks. Allow those listed to release any and all information concerning your injuries to those listed.

If you should choose to refuse to sign any of these, please write "Refused to Sign," on the signature line with the date. Please note, your refusal to sign any consent form(s) may affect your eligibility with UWF.

A. MEDICAL CONSENT

I hereby authorize the athletic trainers at the University of West Florida (UWF) who are under the direction and

guidance of the UWF Athletic Training Department Medical Director, to render to

__ (Print Name)

any preventative, first aid, rehabilitative, emergency treatment that they deem necessary for my health and well-being.

I also grant permission to the physicians and/or their consulting physicians utilized by the UWF Athletic Training

Department to render to

(Print Name) and treatment, medical, or surgical care that

they deem necessary for my health and well-being. Also, when necessary for executing such case, I grant permission for

hospitalization at an accredited hospital. I also hereby grant permission to the UWF Athletic Training Department to

provide any necessary transportation related to any preventive, first aid, rehabilitative, or emergency treatment that they

deem necessary for my health and well-being. I understand and agree that I will be primarily covered for any bodily

injury related to such transportation by my or my family's automobile policy and I agree to submit any medical bills

incurred to such insurance company for payment. If the policy has been issued with a deductible clause relative to the

personal injury protection, I understand that I have assumed the deductible amount when the policy was purchased.

________________________________________ Print Name of Student-Athlete

___________________________________ Date

________________________________________ Signature of Student-Athlete

________________________________________ Signature of Parent/Guardian if under age 18

Medical Consent Forms

1/5

Student Athlete Initials:

University of West Florida Sports Medicine

B. MEDICAL CARE STATEMENT

The University of West Florida Athletic Department (Athletics) and the University of West Florida (UWF) are committed to providing high quality medical care to its student-athletes. The UWF Athletic Department will provide necessary, reasonable and customary medical care for athletic related injuries/illnesses as permissible under the rules of the NCAA. The provisions to receive the benefits from the UWF Athletic Department are outlined in the following paragraphs.

The University of West Florida is responsible only for injuries or illnesses occurring as a direct result of participation in approved conditioning, practice, and contests. All injuries will be referred to physicians utilized by the UWF Athletic Training Department or those they designate. Any medical or dental expenses that occur outside of UWF approved athletics participation cannot and will not be covered by UWF.

UWF is responsible for only those student-athletes who are official members of the intercollegiate athletics programs. Medical expenses recorded after the student athlete has been released by the physician will no longer be the responsibility of the University.

HMOs: If a student-athlete's primary insurance is an HMO, the UWF Athletic Training Department strongly encourages

the student-athlete to change the primary care physician (PCP) to a UWF Team Physician or local physician. This will allow the student-athlete to have a network of physicians in the Pensacola area, as well as better access to care. A UWF certified athletic trainer can assist in this process.

Insurance Policy Changes: The UWF Athletic Training Department must receive any changes to a health insurance policy as soon as they

occur. If proper notification is not received, the UWF Athletics Department will not be responsible for any delays in payment, collections notices, credit reports, etc. that occur. If a cancellation of a policy occurs without proper notification, any medical expense incurred during that period will be the responsibility of the student- athlete and/or his/her parent(s) or guardian(s).

Physician Referrals / Consultations: UWF has fostered positive relationships with many medical providers and facilities in the Pensacola area who

have consistently provided high quality service to UWF student-athletes. A certified athletic trainer from the UWF Athletic Training Department will refer student-athletes to these providers, unless extenuating circumstances necessitate a different provider or facility.

All student-athletes must be seen and evaluated by a UWF certified athletic trainer before a referral to a physician will be made. A UWF certified athletic trainer must authorize and properly refer all student-athletes to see a physician or medical consultant. All diagnostic tests must be approved and authorized by UWF. If a student-athlete decides to see a physician/medical consultant, and/or undergo a diagnostic test WITHOUT prior authorization and referral from a member of the UWF Athletic Training Department, or if the student-athlete wishes to see a physician/medical consultant other than the one recommended by the UWF Athletic Training Department, the student-athlete and/or the student athlete's parent(s) or guardian(s) will be financially responsible for any and all medical bills incurred.

Medical Consent Forms

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Student Athlete Initials:

University of West Florida Sports Medicine

Policies and Procedures for Referral for Medical Care and for Payment of Medical Expenses

Members of the University of West Florida intercollegiate athletics teams may be covered for athletic injuries by the University's insurance policy under the following conditions:

1. The student-athlete must be an official member of a UWF intercollegiate athletic team. 2. The injury must have occurred while the student-athlete was engaging in athletic department supervised

conditioning, practice or contests. This policy does not cover injuries incurred during tryouts. 3. The student-athlete must have a written physician referral from the Athletic Training Department. UWF has

fostered positive relationships with medical providers in the Pensacola area who have consistently provided high quality service to UWF student- athletes. Members of the UWF Athletic Training Department will refer student-athletes to these providers, unless extenuating circumstances necessitate a different provider. All student-athletes must be seen and evaluated by a certified athletic trainer before a referral to an approved physician will be made, except in cases of medical emergency. In such cases, student-athletes are required to notify the Athletic Training Department of their injury as soon as practical. Appropriate referrals are required for diagnostic testing and follow-up care. 4. The medical care must be rendered by the referral physician or designee. 5. The student-athlete must submit a claim for the medical attention to his or her personal insurance for primary coverage. If these conditions are met, the University will submit a claim for the balance remaining to its insurance carrier for secondary coverage after explanation of benefit (EOB's) and secondary statements are received by the Athletic Training Department. It is the student- athlete's responsibility to obtain all necessary claims and EOB's. The UWF Athletic Training Department will assist the student-athlete with this process. The University will submit a claim for primary coverage for those student-athletes who do not have personal health insurance who otherwise meet these conditions. All policy provisions, coverages, and exclusions are listed in the master insurance policy. A copy of the master insurance policy is available through the Athletic Training Department. Medical expenses recorded after the student-athlete has been released by the attending physician are not the responsibility of the University of West Florida.

Claims for second opinions may be submitted for secondary coverage to the University of West Florida insurance carrier as long as the Athletic Training Department provided a referral for the second opinion. Second opinions obtained from physicians not referred by the Athletic Training Department will not be submitted to the University's insurance carrier and are not the responsibility of the University. I HAVE READ AND UNDERSTAND THE ABOVE STATEMENT REGARDING THE PROVISION OF PAYMENT FOR MEDICAL CARE.

________________________________________ Print Name of Student-Athlete

___________________________________ Date

________________________________________ Signature of Student-Athlete

________________________________________ Signature of Parent/Guardian if under age 18

Medical Consent Forms

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Student Athlete Initials:

University of West Florida Sports Medicine

C. SHARED RESPONSIBILITY FOR SPORTS SAFETY

Participation in athletics requires an acceptance of the possibility of risk of injury. Athletes rightfully assume that those who are responsible for such activities have taken reasonable precaution to minimize such risk and that their participating peers will not intentionally inflict injury upon them.

Periodic analysis of injury patterns or refinements in the rules and other safety decisions will be made by the UWF Athletic Training Staff and the NCAA. UWF will do its best to ensure compliance with all safety precautions in order to protect all participants.

I have read the above shared responsibility statement. I understand that there are certain inherent risks involved in participating in intercollegiate athletics. I acknowledge the fact that these risks exist and I am willing to assume responsibility for such risks while participating in athletics at the University of West Florida.

________________________________________ Print Name of Student-Athlete

___________________________________ Date

________________________________________ Signature of Student-Athlete

________________________________________ Signature of Parent/Guardian if under age 18

Medical Consent Forms

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Student Athlete Initials:

University of West Florida Sports Medicine

D. AUTHORIZATION / CONSENT FOR RELEASE OF INFORMATION

I, the signee, understand that my health information is protected by the Family Educational Rights and Privacy Act of 1974 (Buckley Amendment) and may not be disclosed without my authorization.

I, the signee, hereby authorize the physicians, athletic trainers, sports medicine staff and other health care personnel representing the University of West Florida Athletic Training Department to release information regarding my medical condition(s) (including, but not limited to: type and severity of injury, prognosis, diagnosis, athletic participation status and related personally identifiable information) to other health care providers, hospitals and/or medical clinics and laboratories, athletic coaches, medical insurance coordinators, athletic and/or university administrators, and my parents/guardians for the purpose of coordinating continuing medical care as necessary.

I, the signee, am voluntarily choosing to participate in intercollegiate athletics at the University of West Florida and understand that giving authorization/consent for the disclosure of this health information is a condition for my participation in intercollegiate athletics at UWF.

I, the signee, agree that once information is disclosed by UWF to a third party, UWF is no longer liable for any further disclosure of the health information by the third party.

I, the signee, understand that I may revoke this authorization/consent at any time by notifying the Head Athletic Trainer in writing, but if I do, I understand it will not have any effect on the actions the University of West Florida officials/representatives took in reliance on this authorization/consent prior to receiving the revocation. This authorization/consent expires one year from the date it is signed.

________________________________________ Print Name of Student-Athlete

___________________________________ Date

________________________________________ Signature of Student-Athlete

________________________________________ Signature of Parent/Guardian if under age 18

Medical Consent Forms

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Student Athlete Initials:

University of West Florida Sports Medicine

Insurance Information

Student-Athlete Name: Student ID #:

Sport: Date of Birth:

Year in School: Fr Soph Jr Sr

Athletic Scholarship?: Yes No

Parent/Guardian Information:

Name(s):

Address:

City:

State:

Zip Code:

Home phone #:

Email Address:

Work phone # (s):

Cell phone # (s):

May we call you at work? Yes No

On your cell phone? Yes No

My son/daughter is NOT covered by any insurance policy.

My son/daughter is covered under the insurance policy carried by:

Father

Mother Self More than one policy* Other

**If the student-athlete is covered under more than one policy, please list the primary information on the front and

secondary on the back.

****PLEASE INCLUDE COPIES (FRONT AND BACK) OF ALL INSURANCE CARDS****

Medical Insurance Information:

Policy Holder's Name:

SS#:

Date of Birth:

Home phone #:

Address:

City:

State:

Zip:

Employer:

Work phone #:

Insurance Company: _

Effective Date:

Address:

City:

State:

Zip:

Insurance phone #: _

Type of Insurance:

PPO HMO Other__

Policy #:

Group #:

Other Insurance Information:

Pharmacy Plan:

Pharmacy phone #:

Is there a separate Pharmacy card (from medical health insurance card)? Yes

No

Dental Plan:

Dental phone #:

Is there a separate Dental card (from medical health insurance card)? Yes

No

Do you anticipate any changes in coverage in the upcoming year? Yes

No

If yes, please explain:

I acknowledge receiving information explaining UWF's insurance policy. I understand the extent of the University's responsibility to scholarship or walk on studentathletes who become injured as a result of participation in an intercollegiate sports program. I authorize the release of any medical information necessary to process claims submitted to my insurance companies. I authorize my insurance company to send payment directly to the provider. If I receive a payment for medical services, I will submit payment to the providers listed on the explanation of benefits from my insurance company. I authorize UWF athletic Department to send insurance information to other medical providers when necessary.

_________________________________________ Student-Athlete or Parent/Guardian Signature

_____________________________________ Date

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